Sepsis and Fall
19. Mr H said Mrs I should not have been left alone as she had sepsis related confusion. Mr H said Mrs I was in a cubicle by herself and had an unwitnessed fall where she broke her ankle. Mr H said if Mrs I had not been left alone, she would not have fallen and broken her ankle. Mrs I said she tried to get out of bed and when she stepped on her ankle it exploded which caused her to fall.
20. The Trust said Mrs I was not alone at the time of the fall as she was about to be assessed. The Trust said Mrs I became unsteady and unwell due to possible urosepsis. The Trust said Mrs I’s fracture was sustained on standing, following her fall.
21. NICE guidance on sepsis says when evaluating the risk of severe illness in people with suspected or a confirmed infection, to use clinical judgement to interpret the NEWS2 score. NEWS2 is a tool used to detect clinical deterioration and by measuring parameters such as a patient’s pulse and respiration rate and calculating a score. It says healthcare professionals should recognise that a score of 5 or 6 suggests a moderate risk of severe illness or death from sepsis.
22. The NICE guidance on sepsis goes on to say clinicians should recalculate the NEWS2 score and re-evaluate the risk of sepsis every hour for those at moderate risk of severe illness or death from sepsis.
23. From the records we can see Mrs I presented to the Trust’s emergency department by ambulance on 4 September as she was feeling generally unwell with a high temperature.
24. We can see Mrs I scored 5 on the NEWS2 chart in the ambulance and presented to the Trust at approximately 1.41pm. In line with the NICE guidance on sepsis, Mrs I was at moderate risk of severe illness from sepsis and the Trust would need to re-evaluate this risk every hour.
25. We can see Mrs I had an initial assessment by a nurse in the emergency department at 2.22pm. It does not appear the Trust checked Mrs I’s observations at this time.
26. We can see Nurse A documented they went to see Mrs I to perform her NEWS2 observations. Nurse A noted on leaving the room they passed the doctor who was on their way in and provided the doctor with the notes. Nurse A reported they heard a bang and saw Mrs I on the floor with the doctor stooped down in front of her.
27. We can see Mrs I told Nurse A her legs gave way, and she fell. Nurse A reported that on Mrs I standing, a click was heard, and the bone could be seen protruding through the skin on Mrs I’s right ankle.
28. In the doctor’s account of what happened we can see the doctor reported Mrs I was stood up when they entered the room. They say Mrs I became unsteady on her feet and fell forward onto her torso. The doctor noted Mrs I had no obvious injuries, and they attempted to help Mrs I onto the bed. The doctor reported when Mrs I tried to stand a crack was heard and her right ankle had broken.
29. We can see at approximately 2.50pm, Nurse B documented they walked past the assessment cubicle and noticed Mrs I sat on the floor with a doctor, nurse, and medical student present. Nurse B offered their assistance and noted Mrs I did not complain of any pain and there were no obvious deformities to her limbs.
30. Nurse B documented they helped Mrs I to get into a standing position, along with other staff members. Nurse B noted that after standing for approximately 30 seconds Mrs I complained of pain in her right ankle. Nurse B documented at this point they noticed an opening to Mrs I ankle and her bone was exposed.
31. Following sustaining the injury to her ankle, we can see the Trust pressed the emergency buzzer and further staff came to assist Mrs I.
32. We do not have the time that Nurse A performed observations on Mrs I. We can see at 2.50pm Mrs I was sat on the floor at the time Nurse B arrived. We think it is likely Nurse A would have arrived to perform observations at around 2.30pm. This would allow time for Nurse A to perform the observations and pass the notes to the doctor. It would also include time for the doctor to enter the cubicle and witness Mrs I becoming unsteady on her feet and falling forward. It would also allow time for Nurse B to arrive and offer their assistance.
33. From the evidence we have seen, we have found the Trust acted in line with NICE guidance on sepsis. On the balance of probabilities, we think the Trust performed observations at approximately 2.30pm, which was 50 minutes after Mrs I’s arrival at the Trust. This is in line with NICE guidance on sepsis which says those at moderate risk of illness from sepsis should have observations repeated every hour.
34. We understand Mr H has told us he believes Mrs I’s fall could have been prevented if she was not left alone. The NICE guidance on sepsis does not say a member of staff should be present for continuous monitoring. It says patients with a NEWS2 score of 5 should be monitored every hour, which we can see the Trust did.
35. We do not think, even if the Trust had monitored Mrs I more closely, we could say it could have prevented her fall. This is because we think Mrs I was not alone at the time of her fall, as a doctor was present, and she still fell. We recognise Mr H does not agree with this version of events and will be disappointed by our decision.
36. Based on the evidence we have found Mrs I was not alone when she became unsteady on her feet and fell forward. We can see Mrs I’s fracture was sustained on standing, and not from the initial impact. We will next look at what should have happened following Mrs I’s fall.
37. NICE guidance on falls says older people who fall during a hospital stay should be checked for signs or symptoms of fracture before they are moved.
38. We can see the doctor documented they did a screen to assess for any injury and asked Mrs I if she was in any pain. The doctor noted Mrs I reported feeling unwell and complained of pain in her knee. The doctor documented there were no apparent injuries, and that the door had broken her fall. We can see that five staff members, including the doctor, helped to support Mrs I into a standing position. We can see it was on standing, that ‘a crack was heard’ and Mrs I’s right ankle was noted to have broken.
39. Our ED nurse adviser said Mrs I was assessed by an appropriate health professional for signs and symptoms of fracture before she was moved. They said based on this assessment, it was appropriate to allow Mrs I to stand and try and support her safely back to the hospital bed. Our ED adviser said the Trust could have provided more thorough documentation of the assessment it conducted, but that from the notes, it was clear there was no indication of injury.
40. We have found the Trust acted in line with NICE guidance on falls. We can see it assessed Mrs I and only when it deemed it safe to do so, attempted to support Mrs I into a standing position.
41. We can see Mrs I unfortunately sustained a fracture to her right ankle on standing. We have found the Trust checked Mrs I for signs of fracture before attempting to move her, and this is in line with NICE guidance on falls. We are unable to say the fracture Mrs I suffered was due to a failing by the Trust.
42. In summary, we have found it was in line with NICE guidance on sepsis that Mrs I was not continuously monitored. We have found the Trust acted in line with guidance in performing observations every hour.
43. We understand Mr H’s concerns that Mrs I had an unwitnessed fall due to being left alone. From the evidence we have seen, we do not think Mrs I was alone at the time of the fall. We can see both Nurse A and the doctor have reported the doctor was present and witnessed what happened. We hope this provides re-assurance to Mr H that Mrs I was not alone, and it does not appear the fracture occurred due to the initial fall.
44. We have also found the Trust acted in line with NICE guidance on falls. We can see the Trust assessed Mrs I before trying to move her, and only attempted to move her once it established there were no signs or symptoms of fracture.
45. We acknowledge the pain Mrs I must have experienced at the time of these events, and we recognise the ongoing impact this has had on both her and Mr H. We understand our decision is going to be very upsetting for Mr H and Mrs I. We recognise this decision is not the outcome they were hoping for, and we apologise for any distress this may cause.
Communication
46. Mr H said the Trust did not contact him to let him know that Mrs I had been admitted with sepsis. Mr H said it was his daughter who informed him that Mrs I had been admitted. Mr H said he was the next of kin and should have been contacted. Mr H said if the Trust had contacted him, he would have been with her, and she wouldn’t have fallen.
47. NMC the Code says nurses should share information with patients and their families about their health, care, and ongoing treatment in a way they can understand. Our ED nurse adviser explained there is no specific guidance regarding contacting the next of kin on admittance.
48. From the records we can see Mrs I presented to the Trust’s emergency department by ambulance. We can see Mr H is listed as Mrs I’s next of kin and her daughter’s contact details had also been handwritten on as next of kin.
49. As set out above, we know Mrs I suffered a fall and fractured her ankle whilst in the emergency department. Following this, the Trust asked for her consent to contact her daughter which she provided. We can see the Trust contacted Mrs I’s daughter to let her know her mother was in the emergency department, and she had suffered a fall.
50. From the evidence we have seen, we have found the Trust has acted in line with NMC the Code. We can see the Trust requested Mrs I’s consent to inform her daughter of her admittance, and subsequent fall, which she provided. This is in line with NMC the Code which says nurses should share information with patients’ families regarding their health and care.
51. We understand Mr H has told us he was listed as Mr I’s next of kin and should have been informed of her admittance. We have seen Mrs I’s daughter was also listed as next of kin. This makes it difficult for us to say the Trust should have contacted Mr H rather than Mrs I’s daughter. We understand it was distressing for Mr H to learn of Mrs I’s admittance from his daughter.
52. We have found the Trust took the steps in line with the guidance to contact Mrs I’s family member. We can see Mrs I’s daughter was listed as her next of kin, and the Trust gained consent from Mrs I to contact her and provide information on her admittance. We have found this is in line with NMC the Code.
53. We understand Mr H is concerned that he could have been present at the time of Mrs I’s fall if the Trust had contacted him. We can see Mrs I became unsteady and fell approximately 50 minutes after presenting to the Trust. As described above, Mrs I had just been reviewed by a nurse, and a doctor had arrived to complete an assessment at the time of her fall.
54. As set out in the section above, we do not think Mrs I was alone at the time of her fall. We are unable to say if the fall could have been avoided if Mr H was present. We understand this will be upsetting for Mr H due to the concerns he has raised about this.
55. Mr H also said the Trust had poor communication regarding Mrs I condition throughout her admittance. Mr H said because the Trust didn’t communicate, they never knew what was happening, or what Mrs I’s prognosis was.
56. On 6 September at 12pm the Trust contacted Mr H as Mrs I was confused and was asking for him. We can see Mr H informed the Trust he was on his way to visit her.
57. We can see the Trust noted Mrs I would require surgery on her foot, but she was not medically fit enough at that time due to her existing co-morbidities. At 2pm on 6 September we can see the Trust explained to Mrs I and her stepdaughter that it was unable to perform the procedure on her foot. It explained Mrs I was not currently medically fit, and it would review this again tomorrow. At 5.34pm we can see the Trust noted Mrs I had delirium and asked if a relative would be able to stay overnight to offer family support.
58. We can see Mrs I was visited by her family on 7 and 8 September following the surgery, and the Trust noted it updated them on her condition. We can see there are multiple entries within the records from admission to the 9 September that Mrs I was confused, and the Trust queried if it was delirium. We have not seen any evidence from the 9 September onwards that Mrs I was still experiencing confusion.
59. On 18 September we can see the Trust discussed a skin graft with Mrs I for her ankle. At this time Mrs I was not noted to be confused and it was documented she was administering her own insulin, eating and drinking well, and needed minimal assistance.
60. Our nurse adviser explained that once a patient has capacity to retain information, it is expected that they will update their family independently. It is also important to note that it is documented Mrs I was visited by family members regularly.
61. On 7 October the Trust discussed Mrs I’s discharge with Mr H and the package of care that will be required. Mrs I was discharged on 15 October.
62. We have also seen numerous references throughout the medical records to updates being provided to Mrs I’s family. These references are undated, so we have been unable to say when they happened.
63. From the evidence we have seen, we have found the Trust has acted in line with NMC the Code. We can see when Mrs I was reported to be confused (early in her admittance) the Trust communicated with family more regularly. We can also see the Trust asked family members to stay overnight when needed.
64. We have seen evidence of communication at relevant stages of Mrs I condition, such as when she was confused, discussions pre and post-surgery, and to arrange discharge plans. This is in line with NMC the Code which says nurses should share information with patients’ and their families regarding their health and ongoing treatment.
65. We do not underestimate how distressing this time was for Mr H. We understand receiving additional information may have provided him with reassurance about Mrs I’s condition. We recognise our decision is not the outcome Mr H was hoping for. We would like to assure Mr H that we have carefully considered what he has told us when reaching our decision.
Complaint
66. Mrs I said the Trust responses were very delayed and took 10 months and 14 months to be issued. Mrs I said she had to contact the Trust to request a timeframe of when she would receive the response, and she was informed it should already be with her. Mrs I said this quickly changed to the response was waiting to be signed off. Mrs I said 10 months and 14 months is too long to wait for answers.
67. The NHS complaint regulations say if the organisation does not send the complainant a response within six months, the organisation must notify the complainant in writing accordingly and explain the reason why. It says the organisation must also send the complainant in writing a response as soon as reasonably practical after the relevant period, which is six months after receiving the complaint.
68. The Trust’s patient relations policy says it will ensure that concerns which cannot be resolved at the point of contact, should be investigated and managed in accordance with the wishes of the person raising the concern. It also says timescales for completion will be agreed between the patient relations department and the complainant.
69. We can see Mrs I’s daughter raised concerns on her behalf on 7 September 2019 to the Trust’s Emergency Department. We can see on 25 September the matron of the Emergency Department discussed Mrs I’s concerns with her daughter by phone and sent a letter the same day. In the letter it confirmed it would investigate the fall Mrs I suffered. The Trust did not provide a timescale for completing its investigation within this letter. On 3 July 2020 we can see the Trust issued its findings on the investigation it had conducted.
70. It appears the Trust’s Emergency Department internally investigated the concerns raised, instead of opening a complaint or forwarding Mrs I’s concerns to the patient relations team or PALS. The Trust has been unable to provide a reason for why it responded to Mrs I’s concerns in this way.
71. We understand Mrs I and her daughter believed they had raised a complaint. However, instead of dealing with this as a complaint and referring this to the Patient Relations team, in line with its patient relations policy, the Emergency Department investigated this. Based on this, we have found the Trust did not act in line with its patient relations policy as it did not manage Mrs I’s concerns as a complaint, which is what she believed was happening.
72. Due to the Emergency Department internally investigating the concerns raised, instead of opening a complaint, it meant that the timescale for completion was not discussed. This is not in line with the Trust’s patient’s relations policy which says this discussion should take place between the complainant and the patient relations team. We think the Trust not having this discussion with Mrs I meant the response she received was delayed. This is because it does not appear the Trust was working towards a deadline, or completion date, as there was not one discussed or provided.
73. We have found the Trust also did not act in line with the NHS complaint regulations. We acknowledge the Emergency Department conducted an investigation, instead of dealing with Mrs I’s concerns as a complaint. However, as explained above, Mrs I’s daughter was under the impression a formal complaint had been raised. We think 10 months is a long time for this investigation to be completed. We can see this investigation only occurred due to the concerns raised by Mrs I’s daughter. Therefore, we think the Trust should have provided a response within the six-month timeframe as set out in the NHS complaint regulations.
74. We understand due to pressures related to COVID-19 this may have affected the speed at which the Trust was able to respond. However, we have not seen any evidence the Trust informed Mrs I or her daughter of the reasons for the delay or an expected timeframe of completion. We think this was impacted by the Trust not treating Mrs I’s concerns as a complaint, as it did not discuss the timescales of completion. Based on this we have found the Trust did not act in line with NHS complaint regulations as it took 10 months to issue its response and did not explain the reasons for the delay.
75. We will now look at the second complaint raised.
76. On 25 September 2020 we can see Mrs I’s stepdaughter raised a complaint into the care and treatment her stepmother was receiving from the Trust. The Trust acknowledged this by letter on 2 October. Within the acknowledgement letter the Trust sent a consent form for Mrs I to complete to allow her stepdaughter to deal with this complaint on her behalf. The Trust said it would aim for a completion date of 65 working days from the date it received the signed consent form. We can see Mrs I completed this on 9 October.
77. We can see the Trust issued its response on 30 November 2021 and apologised for the delay in responding to the complaint.
78. We have found the Trust did not act in line with NHS complaint regulations when responding to Mrs I’s stepdaughter. We think the initial timeframe of 65 working days was reasonable, especially considering the extenuating circumstances of COVID-19. This timeframe was also in line with the NHS complaints regulations.
79. We can see Mrs I returned the signed consent form on approximately 9 October 2020. If we allow one week for this to be received by the Trust, the clock for the 65-day completion would start on 15 October. This means the Trust should have issued its response on approximately 19 January 2021.
80. The Trust did not issue its response for a further 10 months from the estimated date of completion. We have not seen any evidence the Trust contacted Mrs I or her stepdaughter to advise it was not able to meet the date of completion, or to provide an explanation for the delay.
81. We have found this is not in line with NHS complaint regulations which says complaints should be completed within six months and an explanation should be provided if the Trust is unable to do so. As explained above, we have also found the Trust dd not act in line with its patient relations policy. We will consider the impact of this below.
82. Mr H has told us the Trust’s complaint handling exacerbated Mrs I’s distress, as she was left without answers to her concerns. Mr H said they felt dismissed by the Trust and having to chase it for a response worsened Mrs I’s anxiety.
83. We recognise the Trust taking 10 months and 14 months to provide a response would have been distressing for both Mr H and Mrs I. Particularly as Mr H believes Mrs I was alone at the time she sustained the injury to her ankle; it is a long time to wait for answers to their questions.
84. We understand having to continue to chase the Trust for answers would have worsened Mrs I’s anxiety at an already difficult time for her and left her and Mr H feeling dismissed. We have found failings in relation to this part of the complaint, and that these had an impact on Mr Whitehouse and Mrs I. We have set out our recommendations to address this below.